Provider Demographics
NPI:1366184053
Name:ROSE, CREA
Entity type:Individual
Prefix:
First Name:CREA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 E MCCORD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3610
Mailing Address - Country:US
Mailing Address - Phone:618-899-9200
Mailing Address - Fax:
Practice Address - Street 1:126 N HOTZE RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-5237
Practice Address - Country:US
Practice Address - Phone:618-495-4241
Practice Address - Fax:618-495-4143
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025104363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner